Patients' Diversity Is Often Discounted

When
UCLA researchers reviewed the best available studies of psychiatric
drugs for depression, bipolar disorder, schizophrenia and attention
deficit disorder, they found that the trials had involved 9,327
patients over the years. When the team looked to see how many patients
were Native Americans, the answer was . . .

"I don't
know of a single trial in the last 10 to 15 years that has been
published regarding the efficacy of a pharmacological agent in treating
a serious mental disorder in American Indians," said Spero Manson, a
psychiatrist who heads the American Indian and Alaska Native Programs
at the University of Colorado Health Sciences Center in Aurora. "It is
stunning."

Native Americans are not the only group
for whom psychiatrists write prescriptions with fingers crossed, the
researchers at the University of California at Los Angeles found as
they reviewed the data for a U.S. surgeon general's report: Of 3,980
patients in antidepressant studies, only two were Hispanic. Of 2,865
schizophrenia patients, three were Asian. Among 825 patients in bipolar
disorder or manic depression studies, there were no Hispanics or
Asians. Blacks were better represented, but even their numbers in any
one study were too small to tell doctors anything meaningful.

In all, just 8 percent of the patients studied were minorities.

It
is but one example of a larger pattern: Scientists have broadly played
down the role of cultural factors in the diagnosis, treatment and
outcome of mental disorders. In part, this is because modern psychiatry
is based on the idea that mental illnesses are primarily organic
disorders of the brain. This medicalized approach suggests that the
symptoms, course and treatment of disorders ought to be the same
whether patients are from the Caribbean, Canada or Cambodia.

This
model has produced striking successes. Neuroscientists have uncovered
key details about how the brain functions and malfunctions, and drug
companies have found many effective medications. More patients than
ever before have received treatments that have been proven to work.

As
the population of the United States grows ever more diverse, however,
this approach is facing challenges from within the profession's own
ranks. A growing number of advocates for "cultural competence," many of
whom are minorities themselves, warn that doctors are harming patients
by ignoring evidence about the effects of ethnicity, sex, religious
beliefs, social class and national origin on mental health and mental
illness.

"The [drug] companies are thinking about
the average Caucasian, male patient," said psychiatrist Michael Smith,
at UCLA's Research Center on the Psychobiology of Ethnicity, who
bemoaned the vacuum of information about drug metabolism and side
effects among various groups. Some minorities' distrust of drug trials
further compounds the problem, he and other researchers said.

"This
thing called psychiatry -- it is a European-American invention, and it
largely has no respect for nonwhite philosophies of mental health and
how people function," agreed Carl Bell, a psychiatrist at the
University of Illinois at Chicago.

"A lot of
minority groups perceive psychiatric interventions as an ideological
approach that discounts their own cultures," added Marcello Maviglia, a
psychiatrist who has worked extensively with Native American patients
in New Mexico. "A lot of people wouldn't be able to verbalize this, but
patients know when you are discounting them, their traditions."